Healthcare Provider Details

I. General information

NPI: 1194319202
Provider Name (Legal Business Name): STEPHANIE BERRELLEZA ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 H38 RD
DELTA CO
81416-3328
US

IV. Provider business mailing address

1554 H38 RD
DELTA CO
81416-3328
US

V. Phone/Fax

Practice location:
  • Phone: 970-985-1491
  • Fax:
Mailing address:
  • Phone: 197-098-5149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0022606
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: